Endocrine Abstracts

We present a case of discordant pituitary biochemistry which resolved after discontinuing a commercially available combination vitamin supplement. A 35 year-old man presented following an episode of headache and dizziness, preceding collapse and possible seizure activity. Investigations revealed deranged pituitary function: TSH 0.02 mU/l (0.35-5.50), fT4 3.6 pmol/l (10.0-20.0), 9 am cortisol 18 nmol/l (200-500), testosterone >52 nmol/l (8.4-28.7), FSH <0.3 U/l (1.0-18.0), LH <0.1 U/l (2.0-9.0), oestradiol 611 pmol/l (0-146), prolactin 452 mU/l (45-375) IGF-1 207 ng/ml (71.0-234.0). He reported weight gain, low mood, sweats, and reduced libido. 7 months prior he had sustained a head injury from a concrete block. He was commenced on hydrocortisone and levothyroxine. MRI found normal pituitary gland and surrounding structures. On further questioning at follow-up he admitted taking a combined nutritional supplement called ‘Kodiak Coma’. Based on clinical suspicion that the supplement was contributing to the derangement in pituitary function tests the patient was asked to stop taking it. Subsequent pituitary function tests returned to normal, with normal short synacthen test (0 min 249, 30 min 659 nmol/l). He was able to discontinue hydrocortisone and remained well. He continued to take levothyroxine replacement for primary hypothyroidism. None of the listed ingredients in ‘Kodiak Coma’ are known to affect pituitary function or related hormonal axes and the discordant biochemical picture did not correlate to this patient’s clinical presentation. Rather we hypothesise that a component or components of the supplement caused assay interference. Biotin is commonly included in nutritional supplement preparations; it is well known to interfere with certain assays of thyroid function, and rarely has been reported to interfere with other pituitary hormone assays. However, a different pattern of interference would have been expected if biotin was the culprit. The manufacturer of Kodiak Coma was contacted for information about its ingredients, but no reply was forthcoming. Nutritional supplements are often marketed towards individuals with no underlying deficiency, illness, or disease. Such products are readily available in high street shops and online. However, it is well documented that active ingredients in products of this kind can lead to negative health outcomes, either by drug interaction, by unintended effect upon clinical investigations, or by a direct effect to cause disease. This patient was subjected to a 4-day hospital admission, medical therapy, and several months of clinical and biochemical follow-up as a result. This case illustrates the unintended risks of nutritional supplements and highlights a potential cause for discordant pituitary biochemistry.